Contractual Status There must be an executed ... - …

1 March 1, 2019 aetna Institutes of excellence Transplant Facilities Summary of Criteria Requirements for Consideration Request For Information (RFI): Facility must submit a completed, current year, standardized response to the RFI. Access: aetna must determine that it has a need for facility s specific transplant services in its Institutes of excellence network. Contractual Status : There must be an executed , participating agreement covering pre- and post-transplant care facilities, physicians, and all other related inpatient and outpatient costs. All physicians providing transplant services must be participating with aetna .

2 Designation Process: aetna s Institutes of excellence Oversight Committee (IOEOC) has sole discretion in making final determinations on eligibility. Program Criteria: Facility Certification All facilities must maintain accreditation by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). All solid organ transplant programs must have Medicare certification and funding and be a United Network for Organ Sharing (UNOS) member in good standing. All bone marrow transplant (BMT) centers must be fully accredited by the Foundation for the Accreditation of Cellular Therapy (FACT) and certified by the National Marrow Donor Program (NMDP).

3 National Cancer institute (NCI) designation is preferred, but not mandatory. Data Management Programs must have the ability to collect, analyze and report data, and must submit updated information to aetna annually. Program Processes Facility must agree to provide written notice to aetna of any changes in its ability to deliver services to our members. Facility must maintain a staffing list and protocol list that can be shared with aetna upon request. Facility must be willing to allow site visits with appropriate National Medical excellence Program (NME) staff.

4 Facility must disclose and explain any history of closure or suspension to the satisfaction of the Institutes of excellence Oversight Committee (IOEOC). Facility must maintain general and professional liability and other insurance, as necessary. March 1, 2019 Staff Each solid organ program must have a UNOS-approved primary surgeon and primary physician. All facility staff must be properly credentialed by aetna , privileged and reappointed within the scope of their specialty at facility. Quality Improvement A quality improvement program must be in place for each program to the satisfaction of the IOEOC.

5 Organ-Specific Criteria: Volume requirement varies by each transplant type. The minimum volumes per calendar year are listed below: Transplant type Adult program Pediatric program Kidney 15 4 Liver 30 10 Heart 12 5 Lung 15 1 Heart/Lung NA NA Pancreas/SPK NA NA Intestine 1 1 BMT 40 (at least 10 allogeneic) 10 Outcomes: For solid organs, 1-year patient and graft survival are evaluated, and both cannot be statistically lower as determined by Scientific Registry of Transplant Recipients public data. For BMT, 3 consecutive years (rolling) survival must not be unfavorable as determined by the most recently available CIBMTR Center-Specific Survival Report.

6 Other specific criteria include: For adult heart/lung programs, the lung program must be accepted into aetna s IOE network, and the heart program must be Medicare certified and funded and have UNOS membership in good standing. For pediatric heart/lung programs, the pediatric lung program must be accepted into the IOE network, and the heart program must be active (a facility with zero transplants for the last year is considered inactive) and have UNOS membership in good standing. If a facility that transplants adult kidneys wants to be considered for pediatric kidneys, it must show that at least 25 percent of its total reported pediatric cases occur in patients between 0 and 10 years of age.

7 A summation of kidney transplants and kidney/pancreas transplants will be used to determine a transplant center s volume for kidney transplants. For pancreas/SPK transplant programs, the adult kidney transplant program must be accepted into the IOE network, and the pancreas transplant program must be Medicare certified and funded and have UNOS membership in good standing. aetna retains the sole discretion to determine designation as an Institutes of excellence facility after taking into consideration all of the program criteria, including cost, accessibility and business needs.

8 Satisfaction of the program criteria is not a guarantee of designation. aetna is the brand name used for products and services provided by one or more of the aetna group of companies. ( aetna )March 1, 2019